What does a honeycomb-like pattern on gallbladder imaging indicate and how is it managed?

Gallbladder Honeycomb Pattern: Diagnosis and Management

A honeycomb-like pattern in the gallbladder represents a rare form of acquired pseudo-multiseptate gallbladder associated with chronic cholecystitis and cholelithiasis, requiring cholecystectomy as definitive treatment. 1

What the Honeycomb Pattern Represents

The honeycomb gallbladder is a distinct entity characterized by:

• Thin pseudo-septations arising from the gallbladder wall that bridge the lumen from side to side, creating a characteristic honeycomb appearance with small stones trapped within the compartments 1
• Development over a chronic inflammatory course following acute cystic duct obstruction, distinguishing it from congenital multiseptate gallbladder 1
• Association with chronic cholecystitis and gallstones in elderly patients who may be asymptomatic with normal laboratory values 1

Imaging Characteristics

Ultrasound Findings

• Hyperechoic collection with acoustic shadowing on the inferior surface of the liver, which is the typical sonographic appearance 1
• The pattern must be distinguished from other gallbladder pathologies including adenomyomatosis, which shows comet-tail artifact at gray-scale imaging or twinkling artifact at color Doppler imaging due to intramural cholesterol crystals and Rokitansky-Aschoff sinuses appearing as intramural cysts 2

Cross-Sectional Imaging

• CT demonstrates multiloculated gallbladder appearance, helping to characterize the extent of septation 1
• MRI can be useful for problem-solving when ultrasound findings are equivocal, particularly to exclude other pathologies like adenomyomatosis or gallbladder carcinoma 3, 4

Critical Differential Diagnoses to Exclude

Adenomyomatosis

• Shows mural hyperplasia that may be diffuse, focal, or segmental with characteristic artifacts 2
• Rokitansky-Aschoff sinuses can be definitively diagnosed by demonstration of cystic-like structures in the gallbladder wall on MRI 2

Porcelain Gallbladder

• Presents as hyperechoic semilunar structure with acoustic shadowing or biconvex curvilinear echogenic structure 5
• Strong association with gallbladder carcinoma, particularly when showing biconvex pattern 5

Gallbladder Carcinoma

• May present with focal wall thickening ≥4 mm adjacent to a mass, sessile morphology, or concurrent liver masses 2
• If there is suspicion for invasive or malignant tumor, immediately refer to an oncologic specialist rather than following routine surveillance algorithms 3

Management Algorithm

Step 1: Optimize Initial Imaging

• Perform transabdominal ultrasound with high-frequency probes and color Doppler to characterize the gallbladder wall and septations 3
• Document presence of gallstones, wall thickening, and any suspicious features 3

Step 2: Advanced Imaging if Needed

• If differentiation from adenomyomatosis or malignancy is challenging, contrast-enhanced ultrasound (CEUS) should be the next step, providing superior characterization through enhancement patterns 3, 2
• MRI should be considered if CEUS is not readily available, with attention to T1/T2 signal characteristics and enhancement patterns 3, 2

Step 3: Definitive Treatment

• Cholecystectomy is the treatment of choice for honeycomb gallbladder from the viewpoint of clinical management, even in asymptomatic patients 1
• This recommendation is based on the chronic inflammatory nature of the condition and association with cholelithiasis 1

Key Clinical Pitfalls to Avoid

• Do not mistake honeycomb gallbladder for simple cholelithiasis with sludge—the pseudo-septations are a distinct pathologic finding requiring surgical intervention 1
• Do not delay surgery in symptomatic patients or those with concerning features, as the chronic inflammatory process can progress 1
• Always exclude gallbladder carcinoma when encountering unusual gallbladder wall patterns, particularly in elderly patients with wall thickening or mass-like features 2, 5
• Surgical risk for cholecystectomy is generally minimal (morbidity 2-8%, mortality 2-7 per 1000 patients) but increases with acute illness and comorbidities, requiring shared decision-making 6